為準備病例報告頭痛嗎？針對藥學系學生的第一次準備就上手喔～

1. 第一次準備病例報告就上手，
如何準備病例報告？
How to Prepare A Case Report Presentation
2015/3/12 (四) 17:10~19:10 @台北醫學大學
新光吳火獅紀念醫院 劉人瑋/張婷雅藥師新光吳火獅紀念醫院 劉人瑋藥師

2. } 檔案在這裡
檔案下載
2
http://goo.gl/ue1QDy

3. 請加入
粉絲團喔~
3

4. } [幫助一] 馬上就會用到，實習一定會有病例報告 (case
report)，今天的課就是要告訴你如何準備
} [幫助二] 從教室走向病房，教室只有學生、病房只有病
人，如何快速掌握病情? 彙整病人的問題，甚至提出解決
方案?
} [幫助三] 什麼是「DTP」? 怎麼寫「SOAP」? 如果你不
知道，一定要看後續報導
這堂課對你有什麼幫助？
4

5. 臨床藥師在幹嗎？
5
護理人員
社工師
營養師
住院醫師
主治醫師
臨床藥師
路人甲

6. } “Pharmacotherapy Casebook: A Patient-
Focused Approach, 8th Edition (2011)”
} [特色]:
- 由美國將近100個機構，超過190位藥師撰寫
之臨床病例
- 配合教科書章節擬訂，每個病例都有清楚的學習目標、參
考章節/文獻
} [意義]:
- 可學到道地且精準的病例繕寫
- 提供初學者快速上手的一本書
教材
6

7. } 哪裡可以取得?
- [書籍] 合記書局 售價1,125元 (ISBN 9780-0717-46267)
- [網路] Access Pharmacy
(http://accesspharmacy.com/caseToc.aspx)
教材
7

8. } [主訴 Chief Complaint]:
- "This is the worst pain I have ever felt in my life.“
主訴一定是以病人的口吻描述，通常描述的症狀/病徵，或就
診原因
} [最近病史 HPI]:
- Gary Roberts is a 68-year-old man admitted to the
ED complaining of chest pressure/pain lasting 20~30
minutes occurring at rest. He describes the pain as
substernal, crushing, and pressurelike that radiates
病例報告 - CC & HPI
8
Note

9. } [最近病史 HPI]:
to his jaw and is accompanied by nausea and
diaphoresis. The pain first started approximately 6
hours ago after he ate breakfast and was unrelieved
by antacids or SL NTG x 3. He also states he has
been experiencing intermittent chest pain over the
past 3~4 weeks with minimal exertion.
最近病史描述的是與本次就診有關的故事，會進一步描述主
訴，包括症狀、發生時間、相關處置等等
病例報告 - HPI
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Note

10. } [過去病史 PMH]:
- HTN
- Type 2 DM
- Dyslipidemia
- CAD with PCI with a bare metal stent 10 years ago
過去病史最好包括疾病、嚴重度/分期、曾經接受的治療 及
治療反應 (是否達治療目標)，例如:
“Chronic kidney disease (Stage VI): eGFR 18 ml/min/
1.73 m2 two weeks ago.”
病例報告 - PMH
10
Note

11. } [家族史 FH]:
- Father died from heart failure at age 75 and mother
is alive at age 88 with HTN and type 2 DM.
家族史並非族譜，僅需描述與疾病相關之家族成員狀況即
可，以直系血親為主 (感染性疾病除外)
} [社交史 SH]:
- (+) Tobacco x 20 years but quit when he received his
BMS 10 years ago; drinks beer usually on weekends;
denies illicit drug use.
病例報告 - FH
11
Note
社交史描述的重點是生活型態

12. } [家族史 FH]: 家族樹 (family tree) 通常沒什麼幫助！
請記錄與「健康」有關的事項，其他的…就…
病例報告 - FH
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冠狀動脈血管疾病掛了！
I
II
III
Coronary artery disease
Traffic accident
男的
女的
Note 車禍也掛了～

13. } [用藥史 Meds]:
- Aspirin 81 mg po daily
- Metoprolol tartrate 25 mg po BID
- Simvastatin 40 mg po QHS
- Metformin 500 mg po BID
- SL NTG PRN CP
} [過敏史 All]: NKDA (no know drug allergy)
用藥史/過敏史必須詳盡，用藥史最好包括遵醫囑性，過敏史
最好包括症狀甚至是再暴露反應，這些都是連續性照護重點
病例報告 - 用藥史
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用藥史應包括藥名、劑量、頻次、用法
Note

14. } [系統總覽 ROS]:
- Positive for some baseline CP on exertion for the
past 3~4 weeks, now with CP at rest
} [理學檢查 PE]:
- Gen: WDWN man, A & O x 3, still with ongoing chest
pain, somewhat anxious
- VS: BP 145/92, P 89, RR 18, T 37.1; Wt 95 kg, Ht
170 cm
- HEENT: PERRLA, EOMI, fundi benign; TMs intact
- Neck: No bruits; mild JVD; no thyromegaly
病例報告 - ROS & PE
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系統總覽描述的是醫療人員對病人的「印象」

15. } [理學檢查 PE]:
- Lungs: Few dependent inspiratory crackles; bi-
basilar rales; no wheezes
- CV: Normal S1 and S2, no MRG
- Abd: Soft, nontender; liver span 10~12 cm; no bruits
- Genit/Rect: Deferred
- MS/Ext: Normal ROM; muscle strength on right 5/5
UE/LE; on left 4/5 UE/LE; pulses 2+; no femoral
bruits or peripheral edema
- Neuro: CNs II–XII intact; DTRs decreased on left;
negative Babinski's sign
病例報告 - PE
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16. 理學檢查是同學們最不熟悉的部份，試著去了解每項理學檢
查結果代表的意義，及這項檢查想要偵測的是什麼? 例如:
- Lungs: Few dependent inspiratory crackles; bi-
basilar rales; no wheezes
代表聽診時，病人吸氣時出現雜音，兩側肺底部有囉音，但
沒有哮喘音
[解析] 醫師藉由聽診得知病人可能有肺水腫 (pulmonary
edema) 的問題，因此將安排胸部X光 或 心臟超音波檢查
病例報告 - PE
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Note

17. } [實驗室檢驗 LAB]:
- Na 134 mEq/L Ca 9.8 mg/dL K 4.4 mEq/L Mg 2.0
mg/dL Cl 102 mEq/L PO4 2.4 mg/dL
- Hgb 14.0 g/dL Hct 44% WBC 5.0 x 103/mm3 Plt 268 x
103/mm3
- PT 12.5 sec aPTT 32.4 sec INR 1.0
- T. chol 159 mg/dL Trig 92 mg/dL LDL 105 mg/dL
HDL 36 mg/dL
- AST 22 U/L ALT 30 U/L BUN 15 mg/dL SCr 1.0
mg/dL Alk Phos 75 U/L HbA1c 7.6% Glu 140 mg/dL
Troponin I 8.6 ng/mL
病例報告 - LAB
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18. 實驗室檢驗值的重點在於判讀，而非高低，因此，應該避免
沒有頭腦的大盤趨勢圖 或 會計報表，而著重於某項 (或某
些) 檢驗值的異常 (或正常) 所代表的意義，例如:
- Troponin I 8.6 ng/ml (0~0.50 ng/ml) [異常]
[解析] Troponin是心肌受損時釋放出來的蛋白質，作為心肌
梗塞診斷與預後指標
- PT 12.5 sec aPTT 32.4 sec INR 1.0 [正常]
[解析] 凝血功能將影響治療策略，決定是否使用抗凝血藥物
病例報告 - LAB
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Note

19. } [心電圖 ECG]:
- ECG taken on arrival in the ED showing ST-segment
elevation in leads II, III, and aVF.
病例報告 - Others
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20. } [評估 Assessment]:
- Acute inferior STEMI
書中並非使用「診斷 (diagnosis)」一字，而是使用「評估
(assessment)」，避免僅列出病名，而非整體評估
} [問題 Questions]:
- Problem identification - Outcome evaluation
- Desired outcome - Patient education
- Therapeutic alternatives
- Optimal plan
病例報告 - A & Q
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Note

21. 藥物相關問題
} 什麼是藥物相關問題 (drug-related problem)?
- 藥物相關問題分類:
國際上藥物相關問題分類眾多，包括ASHP、PCNE等 (Ann
Pharmacother. 2004; 38: 859-67. PMID 15054145)
給藥後給藥前
未治療之適應症
應監測 (治療前)
無適應症治療
劑量、療程、用法不當
應監測 (治療後)
藥物、疾病交互作用
效果不佳、重複處方
有衛教需求
Note
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22. } [問題 Questions]:
- Problem identification
- Which findings in this patient's case history are
consistent with acute STEMI?
- What risk factors for the development of coronary
artery disease are present in this patient?
這些問題多著重於讓同學們練習擷取並整理相關資訊，並進
一步抽絲剝繭列出危險因子；最好能根據症狀 (symptom)/
病徵 (sign) 等線索排列；症狀通常是主觀的，而病徵通常是
客觀的
病例問題 – 病例內容
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練習將病例資訊與疾病相呼應
判斷與疾病有關之危險因子Note

23. 怎麼寫「SOAP」?
} 病歷閱讀/SOAP繕寫
- S-O-A-P是一種「思考」，不是一種「表格」
常見錯誤: 寫 (抄) 的跟醫師一樣 (把診斷當作評估)、沒有問
題為導向 (不知道自己在寫什麼)
醫師版 藥師版
S (主觀) 病患主觀描述、外觀/症狀 同
O (客觀) 病患病史、檢查結果，實驗
室與相關檢查
同，更著重用藥史
A (評估) 診斷或臆測疾病 評估藥物相關問題
P (計畫) 治療或診斷 (疾病) 計畫 治療或診斷 (藥物不良
反應) 計畫
我跟你寫得不太一樣喔!!
Note
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24. } [參考答案 Answers]:
- Symptoms: A substernal, crushing, and pressure-
like chest pain that radiates to his jaw and is
accompanied by nausea and diaphoresis occurring
at rest
- Signs: High troponin I level, abnormal ECG findings
(ST-segment elevation in inferior leads, and right
bundle branches block)
建議可參考疾病診斷標準作答，參考資料包括教科書與疾病
診斷/治療指引 (不要只抄 !!)
病例問題 – 病例內容
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Note
就是「SOAP」中的S&O

25. } [參考答案 Answers]:
- Modifiable risk factors of this patient:
- Lifestyle: Smoking
- Medical: Hyperlipidemia, type II DM, HTN and Hx of
CAD
- Risk factors cannot be modified:
- Age
- Family Hx of CHD
一個重要待常被忽略掉的危險因子是「藥物」，藥師們應試
著篩選是否有藥物可能誘發或導致該疾病的可能性
病例問題 – 病例內容
25
Note
應包括可改變與不可改變的危險因子

26. } [問題 Questions]:
- Desired Outcome
- What is the immediate goal of therapy in this patient?
- How can this goal be achieved using
pharmacotherapy?
應避免空洞的目標: 治癒病人 (cure the patient)、緩解症
狀 (relieve the symptoms) 等
或過度窄化的目標: 醣化血色素 (HbA1c) <7%、血壓
(SBP/DBP) <135/80 mmHg
病例問題 – 病例內容
26
練習列出目前治療目標
針對該目標建議藥物治療
Note

27. } [參考答案 Answers]:
- The short-term goals of treatment for the ACS are:
- Early restoration of blood flow to the infarct-related
artery to prevent infarct expansion
- Prevention of death and other MI complications
- Prevention of coronary artery re-occlusion with re-
infarction
- Relief of ischemic chest discomfort
- Resolution of ST-segment and T-wave changes on
ECG
病例問題 – 病例內容
27

28. 怎麼寫「SOAP」?
} Medical problem: chest pain, not relieved by rest.
S:
O:
A: ST-segment elevated myocardial infarction (STEMI),
additional therapy needed.
P:
藥師版「SOAP」的重點是指出「藥物相關問題」，且之後
的計畫應該根據這個問題擬定目標與對策
28
這個是診斷 (diagnosis)
這是藥物相關問題 (drug-related problem)
Note

29. } [問題 Questions]:
- Therapeutic Alternatives
- What nonpharmacologic therapeutic alternative can
also achieve the immediate goal in this patient?
} [參考答案 Answers]:
- Initial therapy: oxygen (all patients for first 6 hours,
and then as needed to maintain SaO2 >90%)
- Immediate primary PCI: balloon angioplasty or
placement of a bare-metal or drug-eluting intra-
coronary stent)
病例問題 – 病例內容
29

30. } [問題 Questions]:
- Therapeutic Alternatives
- What is the role of adjunctive anticoagulant therapy
during PCI, and how should these therapies be
monitored?
} [參考答案 Answers]:
- Parenteral anticoagulants should be used to patients
undergoing PCI (ACCF/AHA Class I, Level C)
- Consider using enoxaparin at time of PCI in patients
who have not received prior antithrombin therapy
(ACCF/AHA Class IIb, Level B)
病例問題 – 病例內容
30

31. } [參考答案 Answers]:
- Monitor parameters of parenteral anticoagulants:
- Efficacy:
- Safety: S&S of bleeding (e.g. uncontrolled bleeding
from injection sites, hemoglobin drop of unknown
cause)
病例問題 – 病例內容
31
Anticoagulant Parameters
Unfractioned heparin (UFH) aPTT
Low-molecule weight heparin (LMWH) Anti-Xa
Fondaparinux Anti-Xa
Bivalirudin aPTT or ACT除了療效更應該有安全性指標

32. } [問題 Questions]:
- Therapeutic Alternatives
- What is the role of adjunctive antiplatelet therapy
before, during, and after PCI, and how should these
therapies be monitored?
} [參考答案 Answers]:
- Aspirin 162-325 mg should be given (chewed) on
first day of STEMI and continued indefinitely at 75-
162 mg once daily unless “true aspirin allergy”
(ACC/AHA Class I, Level A)
病例問題 – 病例內容
32
藥物治療建議常遺漏「療程」

33. } [參考答案 Answers]:
- Clopidogrel 75 mg orally once daily recommended in
addition to aspirin in patients with STEMI whether or
not they have reperfusion therapy (including
fibrinolytic therapy) (ACC/AHA Class I, Level A),
duration at least 14 days and up to 1 year
- Alternatives to clopidogrel include:
- Prasugrel (Effient) in patients having PCI
(ACCF/AHA Class I, Level B)
- Ticagrelor (Brilinta) 180 mg then 90 mg twice daily
(ACCF/AHA Class I, Level B)
病例問題 – 病例內容
33

34. } [問題 Questions]:
- Therapeutic Alternatives
- What are other important goals of therapy in this
patient?
} [參考答案 Answers]:
- The long-term goals following MI are to
- Control modifiable CHD risk factors
- Prevent the development of systolic HF
- Prevent recurrent MI and stroke
- Prevent death, including sudden cardiac death
病例問題 – 病例內容
34

35. } [問題 Questions]:
- Therapeutic Alternatives
- Based on the history and presentation, what initial
drug therapy is indicated in this patient?
} [參考答案 Answers]:
- The initial drug therapy of this patient would be:
- Aspirin 300 mg ST followed by 100 mg PO QD
- Clopidogrel 300 mg ST followed by 100 mg PO QD
- Enoxparin 1 mg/kg (a maximum dose of 100 mg is
recommended for the first 2 doses) SQ Q12H
病例問題 – 病例內容
35

36. } [參考答案 Answers]:
- Nitroglycerin 10 mcg/min IVF for persistent
discomfort due to ischemia, control of high blood
pressure, or treatment of pulmonary edema
- Carvedilol 12.5 mg PO BID
- Captopril 6.25 mg PO TID
- Atorvastatin 10 mg PO QD
- Metformin 500 mg PO BID (resume after PCI)
藥物治療應有詳盡的藥名、劑量、途徑、頻次，有特定使用
方式則說明
病例問題 – 病例內容
36
Note

37. } [問題 Questions]:
- Outcome Evaluation
- How should the recommended therapy be
monitored for efficacy and adverse effects?
} [參考答案 Answers]:
- Efficacy:
- Relief of ischemic discomfort
- Return of ECG changes to baseline
- Absence or resolution of HF signs
病例問題 – 病例內容
37

38. } [參考答案 Answers]:
- Adverse effects:
病例問題 – 病例內容
38
Drug Adverse effects Monitoring
Aspirin Dyspepsia,
bleeding, gastritis
Clinical signs of bleeding,
gastrointestinal upset;
baseline CBC and platelet
count; CBC platelet count
Q6M
Clopidogrel Bleeding, diarrhea,
rash, TTP (rare)
Same as aspirin
IV Nitrates Hypotension,
flushing, headache,
tachycardia
BP and HR Q2H
針對每一種藥物列出追蹤指標
有追蹤頻率將會更好

39. } [參考答案 Answers]:
病例問題 – 病例內容
39
Drug Adverse effects Monitoring
Enoxaparin Bleeding, heparin-
induced
thrombocytopenia
(HIT)
Clinical signs of bleeding;
baseline SCr, aPTT, INR,
CBC and platelet count;
daily CBC, daily CBC and
SCr
Carvedilol Hypotension,
bradycardia, heart
block, broncho-
spasm, acute heart
failure, fatigue
BP, HR, and clinical signs
of heart failure every shift
during oral administration
during hospitalization,
then BP and HR Q6M
following hospital
discharge

40. } [參考答案 Answers]:
病例問題 – 病例內容
40
Drug Adverse effects Monitoring
Captopril Hypotension,
cough, hyper-
kalemia,
prerenal
azotemia, acute
renal failure,
angioedema
BP Q2H x 3 for first dose,
then every shift during oral
administration during
hospitalization, then once
Q6M following hospital
discharge; baseline SCr and
K; daily SCr and K while
hospitalized
Atorvastatin GI upset,
myopathy,
hepatotoxicity
LFT at baseline, at 6 wks, and
after titration to highest dose,
then annually thereafter;
counsel patient on myalgia

41. } [療程 Clinical Course]:
病例導讀 – 病例內容
41
2/18 15:40 2/21 9:002/18 14:40
ED PCI Echocardio-
graphy
Dx of
STEMI
2/18 8:00
Breakfast
2/18 14:00
Chest
pain onset
Discharged
Post-PCI care
2/18 16:20
PCI
Eptifabatide
MONA, UFH,
and metoprolol
Clopidogrel

42. } [問題 Questions]:
- Patient Education
- Based on his hospital course, which discharge
medications would be most appropriate for this
patient?
- What education should you provide to this patient?
} [參考答案 Answers]:
- For secondary prevention of myocardial infarction,
those are this patient needed…
病例問題 – 病例內容
42

43. } [參考答案 Answers]:
- To prevention LV remodeling following MI
- ACEIs, beta-blockers, and selective aldosterone
receptor antagonists have been shown to prevent it
and reduce mortality of these patients
病例問題 – 病例內容
43

44. } [參考答案 Answers]:
- Aspirin 100 mg PO QD indefinitely
- Clopidogrel 100 mg PO QD at least 1 month
- Carvedilol 12.5 mg PO BID
- Lisinopril 20 mg PO QD
- Atorvastatin 10 mg PO QD
- Metformin 1 gm PO BID
短期 (緩解心肌缺血症狀) 與長期 (預防再次心肌梗塞) 藥物
治療目標不同，應針對目標而有不同治療策略
病例問題 – 病例內容
44
Note

45. } [療程 Clinical Course]:
- Six months later, he states that he is really trying to
exercise more and eat better. He has been taking all
of his medications.
- He states there are some pain in his calves and
thighs, and he thinks at he has it is due to his
walking exercise
regimen he started 4 months ago.
- It is bothering him enough that he has had to stop
walking every day.
病例導讀 – 病例內容
45

46. } [療程 Clinical Course]:
- Labs reveal the following:
- TC 135 mg/dL TG 89 mg/dL HDL 39 mg/dL
LDL 78 mg/dL
- CK 450 IU/L
- Vitals: BP 130/80 mmHg and P 65 bpm.
} [後續問題 Follow-Up Question]:
- What is the cause of this patient's myopathy and
how should his regimen be modified taking into
consideration his adverse effects and his goal LDL?
病例導讀 – 病例內容
46

47. } 內文:
- 字型大小: 10人以上「24」以上為佳
- 字型挑選: 勿使用太細、太扭曲的字體
- 內文呈現: 條列式，勿長篇大論
- 內容數量: 30分鐘約30~35張、50分鐘約40~45張、60分
鐘不要超過50張
} 圖表:
- 大小適中: 填半版以上至少需300x400大小
- 務必清晰: PDF檔向量擷圖最清晰
簡報製作
47
標題重點是「你想告訴聽眾什麼？」

48. } 上台前:
- 放鬆活動: 全身放鬆一下！走走動動會比坐在原地緊張好
- 內容提示: 在投影片中放內容提示比寫稿子死背好
} 演講時:
- 肢體眼神: 肢體 (手為主) 活動較能聚焦，眼神與聽眾要能
接觸 (別只看著螢幕或某個奇怪的地方)
- 語調聲音: 輕重緩急、發音清楚
} 演講後:
- 回答問題: 掌握記錄、點頭、重覆與回覆四項要點
- 解決問題: 擱置爭議、聲東擊西、反問聽眾
演講技巧
48

49. } 提供準備病例報告同學建議:
- 至少花時間練習1~2個病例
- 第1個通常只拿50分，但第2個可以進步到75分
建議參考教科書，並配合最新治療指引
- 從定義、症狀、診斷、治療到預後 [別只看治療]
想要贏在起跑點，只有早點起跑
「從準備報告中學習」才是報告最大 的目的
結語
49
1
2
3